Melanoma & Other Skin Cancers

Treatment for Skin Cancer

The treatment of skin cancers depends on whether the lesion is a non-melanoma or a melanoma. Several treatment options are available for non-melanomas, and the choice depends on many factors, such as the location and characteristics of the tumor (size, depth, and location); the individual’s age, general health condition, and personal preference; and the potential cosmetic result.

Generally, this can be accomplished by excision of the skin cancer with a small margin of the surrounding skin. The surgeon and the pathologist will generally verify that the skin cancer is generally removed with a “quick stain” during the operative procedure. If there is still residual tumor, then more skin must be excised. For melanomas, surgical treatment involves a wider excision of skin surrounding the melanoma in an amount that varies according to tumor thickness. The goals are to remove all cancerous tissue and to minimize the likelihood that the cancer will recur (grow back). Surgical excision is usually the preferred treatment for both types of skin cancer.

In addition to surgical excision of a melanoma, dissection (removal) of lymph nodes that contain cancer cells may also necessary. Surgery is the most effective treatment in this circumstance. If a melanoma is thick or has spread to one or more lymph nodes, the physician may recommend adjuvant therapy after the surgery, which is treatment given after the primary treatment.

The goal of adjuvant therapy is to kill cancer cells that are not yet detectable, and this treatment increases the likelihood that the melanoma will not recur. Adjuvant therapy may include biological therapy (also called immunotherapy) or radiation therapy or both. At present, there is no documented benefit of chemotherapy after surgery. When melanoma is metastatic at the time it is diagnosed, a combination of surgery and radiation therapy may be recommended to eliminate the primary melanoma as well as control the metastatic disease.

Surgical Excision and Lymph Node

Surgical excision involves removal of the melanoma and a small amount of normal tissue around the lesion (known as the surgical margin). The normal tissue is removed to make sure that all cancer cells have been eliminated. This procedure is known as a wide local excision. How wide the excision should be is determined by how thick the tumor is, but it is generally recommended at either a half-inch or an inch of skin surrounding the melanoma. After the lesion has been removed, the margins of the wound are sewn together. 

If sentinel node biopsy was done previously and showed that melanoma had spread, the lymph nodes in the area of the sentinel node may have to be dissected. Sentinel lymph node mapping and biopsy may be done at the time of removal of the melanoma if the physician finds that the melanoma has adverse features, such as cancer cells in the margins. If this testing indicates that the cancer has spread to the sentinel node, another surgical procedure is performed at a later time to remove additional nearby lymph nodes. If stage III melanoma involving pathologically documented spread of cancer to the lymph nodes is found, lymph node dissection is done during the same procedure as the wide excision.

Sentinal Lymph Node Mapping and Biopsy

One of the most important indicators of survival after treatment of a melanoma is whether it has spread. When melanoma spreads, the first place it is most likely to be found is the regional lymph node closest to the melanoma. This lymph node is referred to as the sentinel node. A procedure called lymphoscintigraphy, otherwise known as sentinel node mapping, is done to determine the exact drainage of lymph from the skin surrounding the melanoma into the sentinel lymph node. This procedure is usually considered for melanomas that are more than 1 mm thick.

With sentinel node mapping, a small amount of radioactive substance is injected into the skin around the biopsy site of the melanoma and a device that detects radioactivity is used to follow the path of the substance as it travels to the nearest group of lymph nodes. The surgeon will also inject a small amount of blue dye into the skin around the melanoma at the beginning of the operation as a second tracer to precisely identify the sentinel node. The surgeon then makes a small incision in the area of the lymph nodes and removes the sentinel node that has turned blue and/or become radioactive. The surgeon will remove the sentinel node (sentinel node biopsy), and a pathologist will examine it to determine if melanoma cells are present. If no cancer cells are detected in the sentinel node, it is highly unlikely that the melanoma has spread to any lymph nodes.

Sentinel node mapping and biopsy may not be necessary in every case of melanoma, and an individual should discuss this issue with his or her physician.

Chemotherapy and Immunotherapy

A combination of treatments that may include surgery to remove the melanoma and chemotherapy to treat the metastasis, is needed for stage IV melanoma. Chemotherapy is known as systemic therapy because anticancer drugs travel through the bloodstream to kill cancer cells that have spread beyond the site of the melanoma.

The chemotherapy drugs most commonly used to treat metastatic melanoma include:

  • DTIC (dacarbazine) alone
  • Combination of DTIC, BCNU (carmustine), and Platinol (cisplatin)
  • Combination of DTIC, Platinol, and Velban (vinblastine)Temodar (temozolomide — similar to DTIC but in pill form)

Chemotherapy drugs may be associated with side effects, such as nausea and vomiting, hair loss and mouth sores. These side effects are usually temporary, and treatments are available to help manage them. In addition, chemotherapy can decrease the number of healthy blood cells, which can leave a person feeling tired and weak. A low level of healthy blood cells also makes a person more susceptible to infection or to bruising and bleeding when injured. It is important for individuals to tell their doctor, nurse or other member of the health-care team about side effects so that appropriate treatments can be prescribed to relieve discomfort.

Another treatment option for some melanomas is immunotherapy, or treatment that stimulates the individual’s own immune system to kill cancer cells. The two most commonly used drugs for immunotherapy are interferon-alpha and interleukin-2 (IL-2). These drugs are given in high doses and are most often used for individuals who are participating in a clinical trial.

Immunotherapy may be appropriate if an individual has several melanomas and it is not possible to perform an appropriate wide excision on all of them. Immunotherapy may also be used as adjuvant therapy for melanomas that are thick or have spread to lymph nodes.

Immunotherapy is associated with several side effects, including chills, fever, aches and extreme tiredness. Individuals who are considering immunotherapy should discuss this treatment with their physician to learn about the potential benefits, the likelihood of side effects, and the options for managing these side effects.

 

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